Provider Demographics
NPI:1104981042
Name:DAVYDOVA, YELENA (OD)
Entity type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:DAVYDOVA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8692 LAKE ASHMERE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3203
Mailing Address - Country:US
Mailing Address - Phone:619-957-1616
Mailing Address - Fax:
Practice Address - Street 1:539 PARKWAY PLZ
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2532
Practice Address - Country:US
Practice Address - Phone:619-441-0138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12562T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV01516Medicare UPIN
CAWOP12562Medicare ID - Type Unspecified